Political campaigns increasingly micro-target. Given detailed knowledge of voters’ identities, campaigns try to persuade voters by pandering to these identities. Through multiple survey experiments, we examine the persuasiveness of group-directed pandering. We ask: Do group members respond more favorably to appeals geared to them, or do they prefer broad-based appeals? Do voters not in a group penalize candidates who appeal to a group? Answers to these questions help us grapple with the evolving relationship between voters and candidates in a rapidly changing information environment. Our results suggest that voters rarely prefer targeted pandering to general messages and that “mistargeted” voters penalize candidates enough to erase the positive returns to targeting. Theoretically, targeting may allow candidates to quietly promise particularistic benefits to narrow audiences, thereby altering the nature of political representation, but voters seem to prefer being solicited based on broad principles and collective benefits.
Why are politicians more likely to advance the interests of those of their race? I present a field experiment demonstrating that black politicians are more intrinsically motivated to advance blacks' interests than are their counterparts. Guided by elite interviews, I emailed 6,928 U.S. state legislators from a putatively black alias asking for help signing up for state unemployment benefits. Crucially, I varied the legislators’ political incentive to respond by randomizing whether the sender purported to live within or far from each legislator's district. While nonblack legislators were markedly less likely to respond when their political incentives to do so were diminished, black legislators typically continued to respond even when doing so promised little political reward. Black legislators thus appear substantially more intrinsically motivated to advance blacks’ interests. As political decision making is often difficult for voters to observe, intrinsically motivated descriptive representatives play a crucial role in advancing minorities’ political interests.
A key test of a political system is its capacity to solve important societal problems. Few policy areas in the U.S. are more problem-ridden than health care. Medical care is expensive and wasteful, and the quality often falls short of best practice. One idea to improve health care is to eliminate gaps in the medical evidence base through “comparative effectiveness research” (CER). By identifying what treatments, tests, and technologies work best, CER could help doctors, patients, and payers make better decisions and help reduce wasteful spending. CER was a technocratic, third-tier issue familiar mainly to policy experts based in universities, foundations, and think tanks, but hardly anyone else. This paper traces how this obscure policy initiative got caught up in the wider ideological struggle over national health reform.
We conducted two national surveys of public opinion about comparative effectiveness research and the integration of findings from the research into clinical practice. The first survey found broad support for using research results to provide information, but less support for using them to allocate government resources or mandate treatment decisions. In addition, the public is willing to consider the use of financial incentives to encourage patients to choose cheaper treatments, if research demonstrates that they work as well as more expensive ones. The second survey found that support for comparative effectiveness research dropped in response to general debates about its consequences but that arguments against the research could be effectively countered by specific, targeted rebuttals.
Using research to develop treatment guidelines is one way to lower medical costs and improve care. However, findings from a national survey show that the public is skeptical about this approach. Specifically, the public finds arguments against establishing research-based treatment guidelines more convincing than arguments in favor of it. Our findings suggest that for evidence-based treatment guidelines to win public acceptance, the public needs to be reassured that guidelines would not lead to the limiting of access to beneficial care.
This essay uses the case of the "medical evidence gap" to illustrate how polarization and party competition can undermine efforts to solve a societal problem. Policy experts associated with both parties agree that the lack of hard evidence about what treatments work best for patients with different conditions is a significant health care problem, and that greater investments in "comparative effectiveness research" (CER) would enable patients, providers, and payers to make more informed decisions. Until recently, CER was a technocratic, third-tier issue. Over the past year, however, CER became highly politicized because it got caught up in the partisan struggle over universal health care reform. The story of how CER morphed into a symbol of crude rationing schemes and government interference with the doctor-patient relationship offers a cautionary lesson about the limits of pragmatic governance in an era of polarization.
In an ideal word, doctors would choose what medical procedures to use on the basis of rigorous evidence. In reality, medical procedures may diffuse into clinical practice before they are scientifically evaluated. Once a procedure becomes popular, physicians may keep performing it, even after evidence emerges suggesting that it does not work. A leading example is arthroscopy for knee arthritis, which a landmark study has shown works no better than a placebo operation. We use the arthroscopy case as a window into the capacity of American government to serve citizens' shared interest in effective medicine. We identify severe problems at every stage of the policy process, from evaluation to decision making and implementation. Surgeons have attacked the study on questionable methodological grounds yet they have not insisted on the follow-up trials that would address the problems they claim undercut the study's unwelcome conclusions. In deference to expert opinion, the government has maintained broad coverage of the procedure
under the Medicare program. These outcomes are unsurprising. Medical procedures are not subject to rigorous scientific evaluation in general. While drugs and devices are routinely tested for efficacy, there is no FDA for surgery. We argue that the systematic underevaluation of medical procedures reflects the simultaneous presence of market failures and government failures, and that this problem is not self-correcting.